Residents Are Coming: A Faculty Development Curriculum to Prepare a Community Site For New Learners

Audience This curriculum is designed for emergency medicine attendings in varying years of community practice to prepare them for Emergency Medicine (EM) residents Length of Curriculum 15 months Introduction Emergency medicine is a growing field with new residencies approved every year. A strong, competent cadre of clinical educators is essential to the success of any residency, and new programs have the challenge of developing their clinical faculty into outstanding teachers. There is minimal literature guidance for navigating this transition. Our site is a community tertiary care center in the process of applying for an EM residency. We focus on our experience designing a faculty development curriculum to accommodate the needs of a diverse group of physicians in all stages of their careers. We will demonstrate that a curriculum satisfying all stakeholders can easily be implemented in a way that allows for robust participation without excessive additional administrative burden. Educational Goals Our goal is to prepare community-based EM attendings to be outstanding educators to future residents by augmenting their knowledge of current educational practice and adult learning theory, literature review, and biostatistics. Educational Methods The educational strategies used in this curriculum included lectures, guided discussion, small group discussion, and asynchronous learning. Research Methods This curriculum was implemented in the Geisinger Wyoming Valley Medical center targeted at staff physicians. This educational study was deemed exempt by the institutional review board (IRB). We electronically collected retrospective survey data using a 5-point Likert scale as well as free text responses. The primary measure was agreement with the statement, “Faculty development time makes me feel more prepared to be a clinical educator.” We also surveyed whether this was felt to be an appropriate use of time, self-reported growth in key educational and biostatistical domains, and likeliness to change practice based on the material. Results Responses collected from core faculty after the sessions indicated a uniformly positive review of the series itself with the primary outcome receiving a 4.6 rating on a 5-point Likert scale (strong agreement). Faculty reported that these brief sessions improved the quality of the departmental staff meetings (average rating 4.7/5). Journal club sessions were rated as positive (4.7/5) and attendees self-reported growth in statistical literacy and security in clinical practice. Discussion We demonstrated successful implementation of a faculty development curriculum that was favorably assessed by all key stakeholders. Faculty self-reported growth in all educational and clinical domains evaluated. It was successfully implemented without substantially increasing the time burden for physicians with robust clinical and administrative schedules. We feel this is generalizable to other sites seeking to start an EM residency and is useful for sites with existing residencies to efficiently deliver content to junior faculty. Topics Emergency medicine, faculty development, journal club, virtual learning.

Objectives: Goal 1: EM faculty will become proficient in interpreting the primary literature as it pertains to the daily practice of EM before the arrival of residents and will be able to decide whether and how to modify their practice based on review of selected studies in the primary literature.
Learning Objectives for Goal 1: 1. EM faculty will be able to discuss key basic biostatistical concepts from 2 pre-selected studies every other month 2. EM faculty will be able to cite sources of bias, both external and internal, in studies demonstrated in the primary literature.
3. EM faculty will be able to explain how a patient population included in a clinical trial is either similar to or different from the patients they serve. 4. EM faculty will describe how methodological issues or flaws in study's design and reporting will influence their decision to act on its results in daily practice.
Goal 2: EM faculty will apply modern educational and adult learning theory to their clinical and bedside teaching.
Learning objectives for Goal 2: 1. EM faculty will be able to deliver excellent clinical teaching given the constraints of a busy emergency department 2. EM faculty will provide timely and effective feedback to their learners and produce robust and useful assessments on their progress USER GUIDE Willner

Problem identification, general and targeted needs assessment:
We reviewed the EM-specific Accreditation Council for Graduate Medical Education (ACGME) requirements with particular attention to faculty requirements to initiate a general needs assessment. The ACGME requires all program faculty devote time to practice-based learning and improvement. They also require a core faculty with training in teaching, evaluation, and feedback. 5 Formal targeted needs assessment determined particular knowledge gaps in educational theory as well as biostatistical literacy. To this end we utilized two separate instructional methods. We implemented a bimonthly journal club to improve biostatistical knowledge and increase faculty review of the primary EM literature. We supplemented articles with podcast FOAMed resources intended to increase compliance with article review and to prepare faculty to help future residents determine how to incorporate these resources into their own practice. We utilized a brief lecture format on some aspect of educational theory or clinical medicine delivered at monthly staff meetings to introduce topics related to bedside teaching, assessment, and feedback. Participation in journal club sessions was voluntary. Staff meeting attendance is required, though meetings were conducted virtually during the pandemic.

Goals of the curriculum:
This curriculum seeks to prepare attending emergency physicians in community practice for the arrival of resident learners and augment their teaching of medical students by improving their knowledge of current educational practice and adult learning theory, literature review, and biostatistical literacy.
Objectives of the curriculum: Goal 1: EM faculty will become proficient in interpreting the primary literature as it pertains to the daily practice of EM before the arrival of residents and will be able to decide whether and how to modify their practice based on review of selected studies in the primary literature.
Learning Objectives for Goal 1: 1. EM faculty will be able to discuss key basic biostatistical concepts from 2 pre-selected studies every other month 2. EM faculty will be able to cite sources of bias, both external and internal, in studies demonstrated in the primary literature. 3. EM faculty will be able to explain how a patient population included in a clinical trial is either similar to or different from the patients they serve. 4. EM faculty will describe how methodological issues or flaws in study's design and reporting will influence their decision to act on its results in daily practice.
Goal 2: EM faculty will apply modern educational and adult learning theory to their clinical and bedside teaching.
Learning objectives for Goal 2: 1. EM faculty will be able to deliver excellent clinical teaching given the constraints of a busy emergency department 2. EM faculty will provide timely and effective feedback to their learners and produce robust and useful assessments on their progress

Educational Strategies: See Curriculum Chart
Educational strategies used include virtual lecture supplemented by group discussion and small group discussion in journal club. We delivered a 10-15 minute virtual lecture on a clinical and/or educational topic which was augmented by realtime discussion of challenges and strategies where appropriate via Microsoft Teams. PowerPoint and supplemental materials were available for review via this application. Journal club was delivered in a hybrid format due to constraints on group gatherings due to the COVID-19 pandemic. The authors curated 2 articles for each session. These articles were supplemented with discussion questions to guide review as well as suggested podcasts. We hoped this would improve compliance with article review. Additionally, recent studies have shown many learners use podcasts as a top method of knowledge acquisition. We wanted our faculty to be familiar with this medium so they could prepare to discuss the validity of these resources with trainees. The journal club content is relevant to all learners, and clinical and educational topics are relevant to anyone who participates in medical education at the graduate or undergraduate levels.

Results and tips for successful implementation:
We implemented our curriculum during scheduled staff meetings to avoid increasing time demands. Journal club was held at a rotating time based on the preference of prospective core faculty. The curriculum is still ongoing; we are continuously reviewing to ensure delivery of high-yield content. The target is a 10-person core faculty; however, our department has 48 physicians and APPs, as well as rotating medical students. Quality improvement surveys were delivered to all learners via email for faculty development sessions. Pre-and post-surveys were distributed in person and virtually for Journal club. Basic statistics were performed using Microsoft Excel. Seven out of nine core faculty responded to the survey (the lead author is a member of the core faculty but recused himself). Reviews for the faculty development sessions were uniformly positive. The primary question of interest, "Faculty development time makes me feel more prepared to be a clinical educator," was rated 4.6 on a 5-point Likert scale where 5 represented "strongly agree." They also indicated it was a valuable use of time during staff meetings (4.7/5). Similar approval was found for journal club (4.7/5). When surveyed regarding faculty development lectures, 4 out of 7 respondents agreed that the sessions led them to make changes to their clinical and educational practice, and the rest were neutral.

USER GUIDE
To obtain more specific information regarding faculty's growth in response to journal club, we included a written pre-and posttest with one of the sessions. Three separate faculty members responded. They were asked 3 questions regarding biostatistical literacy both before and after the session. As shown in figure 1 Our ongoing review indicated that faculty prefer a combination of academic theory and clinical practice topics. We suspect this will be the case at other similar sites and recommend inserting topics that are relevant to the department in the lectures indicated in the appendices. Potential sources include interesting cases, departmental Quality Improvement projects, practice issues identified in morbidity and mortality conferences, and requests from faculty. We think the last is especially valuable to increase investment in the curriculum. We have included our chosen topics for reference of depth and breadth of instruction though these can be easily substituted based on local needs.

Chart 1.
Sample pre-and post-Journal Club session selfassessment of biostatistical literacy rated on a 5-point Likert scale (No idea [1] to Know Cold [5]). Q1: I can explain the difference between a derivation and validation study and why it's important. Q2: I can explain the difference between sensitivity/specificity and positive/negative predictive value. Q3: I know what it means to perform a recursive partitioning analysis.

Chart 2.
Pre-and post-session self-assessment of clinical concepts rated on a 5-point Likert scale (Strongly disagree [1] to Strongly Agree [5]). Q1: I feel like I know the current local standard evaluation of a well-appearing febrile infant. Q2: I am more confident in evaluating well-appearing febrile infants after this exercise.

Evaluation and Feedback:
The only element of this curriculum that was poorly reviewed was the virtual journal club sessions. We hypothesize that a certain quorum must be present in-person to sustain critical mass for engaged discussion, less than what social distancing dictated was acceptable. Also, the social benefits including interaction with consultants from other departments outside of the clinical arena are lost. Now that distancing requirements have eased, we have returned to a hybrid model. This allows more robust attendance and dramatically improved participation.
The major weakness of this curriculum study is that its effectiveness in preparing faculty to teach residents was not evaluated because as of this writing, our graduate medical trainees have not started. EM is a required clerkship at our affiliated medical school and student evaluations of our site are consistently high, suggesting good efficacy. 3) Appreciate how to guide novice learners through a new procedure at bedside.

Month 9 9
Atrial Fibrillation (or other clinical topic) and "When you and your trainee disagree" 1) Explain which patients with atrial fibrillation are candidates for cardioversion.
2) Discuss which patients we discharge after cardioversion should be started on anticoagulation.
3) Evaluate strategies to manage the unstable patient with atrial fibrillation. 4) Resolve disagreements with trainees with regards to patient management.

Month 11 10
How to give an amazing chalk talk 1) Explain how to design and deliver a high quality-chalk talk.
2) Discuss evidence-based strategies for preparing lectures for adult learners.
3) Understand how to adapt lectures to a virtual format.

Month 12 11
Bedside Procedure Teaching 1) Discuss the importance of patient-centered procedure teaching.
2) Describe multiple modern frameworks for procedural teaching.
3) Discuss how to maintain learner autonomy during critical procedures.
Month 13 12 *Please note that these topics are not mandatory. We chose them based on our departments needs as identified by morbidity and mortality conference, quality improvement projects, and most importantly, feedback from our faculty. We are providing what we did to give a sense of scale, but we recommend you substitute based on local needs as determined above.

Discussion Questions:
Describe the study? Which patients were included? Which were excluded? How is this different from the first article?
Explain recursive partitioning analysis.
Discuss their statistical methods. Do they strike you as appropriate?
Discuss the results. Do you agree with their conclusions? Any limitations?

Summary Questions
Did you listen to the podcasts? Does their assessment of the articles agree with yours? Why or why not?
Will you change your practice as a result of this discussion? Why or why not? If yes, how? Specifically think about which patients need LP (lumbar puncture) as part of their workup.
There are some standard characteristics of the care provided. How might this differ from our local practice? Please explain your answer to the above question in 1-2 sentences here.

Post-Discussion Reflection
After reading the papers, discussion questions, and participating in the group discussions, please rate your confidence with the following biostatistical concepts:

Summary
These are two well-written articles which potentially allow us to do less invasive testing on our youngest and potentially most stress-inducing patients. The group consensus is that we are not ready to abandon the lumbar puncture (LP) in patients less than 28 days old; however, if family has significant hesitancy about this procedure, this is an avenue for shared decision making. We generally agreed with the podcasts' take on the articles. Our guest pediatrician reminds us that if we forego the LP we should avoid antibiotics (remember these are well-appearing neonates) so as not to cloud the picture for meningitis in the future. Also, 10% of babies with a documented respiratory virus (Flu, RSV) have a urinary tract infection, so you still need a urine sample.
*Author's note* Potentially sick children are a major source of stress for emergency providers. Community emergency physicians don't perform many neonatal LPs, so this is an additional stressor. Furthermore, these articles highlight the process of deriving and validating a clinical decision rule and the PECARN article includes some advanced statistical analysis. Our group conducted this session before the COVID-19 pandemic, and before the American Academy of Pediatrics (AAP) changed their guidelines on this population, so your discussion may vary, and including the new AAP guidelines as a reference would be helpful. We also included a sample curricular assessment tool. This was an overall well-done study looking at the accuracy of using a higher D-dimer threshold to exclude PE in patients with a low pretest probability of disease, defined as a Wells score < 4. The study was conducted in adult outpatients (ie, ED patients) presenting to a university hospital in Canada. Patients with recent major surgery, active anticoagulation, life expectancy < 3 months, and a dimer known to the treating provider prior to assessment of the pretest probability were excluded. Strengths included < 5% loss to follow up and that the study was conducted on ED patients. This was a convenience sample, which is not ideal. The algorithm performed very well with no patients who had a low or moderate pretest probability and a negative dimer who were "ruled out" having venous thromboembolism (VTE) at 90 day follow up. They also report a substantial reduction in use of computerized tomography (CT) imaging compared to standard dimer threshold as well as YEARS and age-adjusted dimer approaches.
Overall, we liked the article and thought it was potentially practice changing, but no one in the group was ready to start using this in their clinical practice without some external validation or total buy-in from the rest of the group. At the very least, this study can be used in shared decision making with patients who might be anxious about receiving radiation or contrast. Entry into this study required some suspicion for PE beyond typical chief complaint so be wary of using this to indiscriminately order D-dimers on all comers.
Below is a summary of their algorithm This is another well-done article answering the uncommon, but always frustrating, question of what to do with pregnant patients whose clinical presentation raises concern for a diagnosis of PE. This study used a modified YEARS protocol to evaluate pregnant patients with a complaint of NEW/WORSE chest pain and/or shortness of breath presenting to the emergency department. They excluded the critically ill, those on anticoagulation, with contrast allergy, or with inability to follow up. Overall, the study performed very well in excluding VTE with only one missed deep vein thromboembolism (DVT) discovered at 90 day follow up.
There are a few items of note here. First is that this technically wasn't a randomized controlled trial. Second is that all the patients lost to follow up were in the low-risk group but this would not have affected the results. They also used only 2-point compression US for DVT studies, which is theoretically LESS sensitive than the multi-site compression with doppler we get in our formal studies. The algorithm was equally safe in all trimesters but was less effective as a rule as trimester increased. This makes physiological sense because we know that D-dimer increases throughout pregnancy, and third trimester is when reflux and some of the physiologic breathlessness symptoms of normal pregnancy are at a peak. Again, this was not a screening tool for all comers; there had to be some suspicion for PE based on attending assessment. The prevalence of PE in this study was similar to the other one, highlighting that, in general, active pregnancy isn't a huge independent risk factor. The postpartum period is, however, and none of us would think twice about radiation then.
Group consensus was more favorable for changing our practice based on this article versus the first, simply because there seems to be no standard way of ruling these patients out and this provides a formal algorithm to do so.

*Author's Note*
This session was conducted virtually, and it did not go particularly well. This was done earlier in the pandemic so there may have been some virtual talk novelty at play. If implementing this again, we would have focused more on discussion of challenging cases and barriers to implementation to start discussion rather than leading with the formal biostatistics material. This is an example of important, recent, and potentially practicechanging articles which we recommend as journal club material.

Background on the paper:
One of the most important parts of understanding a paper is understanding who it DOESN'T apply to. In order to be included, patients had to present to the ED with new or worse chest pain or shortness of breath, and it wasn't applied to all-comers, so there had to be some suspicion for PE by the attending physician. They EXCLUDED the critically ill, those on anticoagulation, with contrast allergy, or with inability to follow up. In general, the methodology was excellent, there was minimal loss to follow up, and the algorithm performed very well. This wasn't technically a trial, but it is about as close as we'll get in this population. Rate of PE/DVT was similar to other studies, so this population probably isn't as high risk as we sometimes imagine it to be.

Specialist Input:
We were joined by two of our colleagues from radiology. Their sense of current practice is that we adequately avoid radiation in these patients. They use special CT protocols in pregnant patients to limit radiation exposure to both mom and fetus. Sometimes a shield is used but if used incorrectly will actually increase the radiation dose the fetus receives. We should be getting chest X-ray (CXR) in these patients because sometimes this will reveal a diagnosis and is useful in follow up. They also highlighted that CT imaging in a coordinated healthcare system such as ours can be useful in monitoring non-acute findings.

Discussion and Bottom Line:
Almost all participants felt that using a risk-adjusted dimer would be appropriate. Important considerations include challenges brought about by long wait times because very low risk patients don't even require dimer testing, and this can be a nuanced decision requiring information potentially not available during the medical screening exam (MSE). Another issue is that our lab will flag a result as abnormal even though it's still "negative" at the high threshold which is a potential challenge with patients having access to their lab results.

*Author's Note*
We had excellent engagement when we invited our specialist colleagues to discuss and join us in a moderated discussion. This article was covered already in a previous journal club, so a simple review of the basic biostatistics elements was all that was required. These were presented ahead of time and attendees were encouraged to bring questions to ask our radiology colleagues. We chose this particular paper because of poor engagement with it in the previous section and out of a hope that the material was novel and practice changing. It is presented here as an example of how one might set up a multi-specialty discussion panel. A paper relevant to a recent interesting or morbidity/mortality case would also work. We would recommend including a sample case from your department relevant to the discussion. An example from this section below: